Double Trouble – Synchronous Primary Malignant Neoplasms: A Case Report

Sejal Jain (1), Amaranathan Anandhi (1), Sathasivam Sureshkumar (1), Deepak Barathi (2), Bheemanathi Hanuman Srinivasan (3), Vikram Kate (1)

1-Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

2-Department of Radio Diagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

3-Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Correspondences to: Dr. Vikram Kate; email: drvikramkate@gmail.com

Received: 12 Apr 2021; Revised: 31 Oct 2021; Accepted: 13 Nov 2021; Available online: 13 Dec 2021

Abstract

Synchronous primary malignancy (SPM) is rare. We herein present a case of gastric carcinoma (GC) and renal cell carcinoma (RCC) to highlight the fact that the occurrence of RCC as a synchronous tumor along with GC is rare and that a high index of suspicion of SPM should be considered before declaring it as a metastasis. A 60-year-old male presented with abdominal pain and vomiting for 4 months, and a mass was incidentally found in the lumbar region. The patient was diagnosed with SPM of the GC and RCC. Chemotherapy was given, followed by total gastrectomy; radical nephrectomy was performed. The patient is currently on follow-up. Complete history taking and thorough physical examination of patients with malignancy is instrumental in ruling out metastasis and other synchronous lesions, especially in GC. Synchronous malignancies should be treated with the multidisciplinary team, as there is no consensus in the treatment protocol.

 

Ann Afr Surg. 2022; 19(2): 121-124

DOI: http://dx.doi.org/10.4314/aas.v19i2.10

 

Keywords: Synchronous malignancies, Gastric carcinoma, Renal cell carcinoma, Multiple primary malignancies

 

Funding: None.

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction 

Multiple primary malignancy (MPM) is the presence of two or more tumors that are not metastases of each other in a patient (1). They can be either synchronous or metachronous. Synchronous primary malignancies (SPMs) are malignancies that occur either simultaneously or within 6 months of diagnosis of the primary cancer, whereas metachronous malignancies are those that occur with a gap of at least 6 months and with the second malignancy usually appearing after the treatment of the first. The prevalence of MPM was reported to be between 0.734% and 11.4% in a review of 1,104,269 patients, with the synchronous type having a much lower proportion (2). The huge difference in the incidence of MPM can be attributed to variations in availability of facilities for diagnosis as well as the varied long-term survival of patients with cancer (3).The various risk factors for the development of MPM are immunological defects, genetic defects such as Li-Fraumeni syndrome, environmental exposure to carcinogens such as cigarette smoke, and previous chemotherapy (4). Increasing clinical knowledge and the development of newer diagnostic techniques have led to increased diagnosis of MPM. This case report emphasizes that MPM poses diagnostic and therapeutic challenges to clinicians. Notably, 0.7% to 11% of gastric carcinoma (GC) has been found to be associated with synchronous malignancies (2, 5). SPMs are usually found in the colon, breast, and lung in descending order of frequency. Renal cell carcinoma (RCC) as SPM is rare (5-7). The incidence of synchronous stomach– kidney tumors worldwide is approximately 0.13–0.42%

 (5). As the incidence of GC with SPM is higher in Asian population, the possibility of second malignancy should be kept in mind (5, 6, 8). Once diagnosed, a meticulous search for genetic and familial risk factors should be done in the patient and the patient’s family. Thus, we herein present a patient with SPM of the stomach and kidney.

 

 

Case presentation 

A 60-year-old male patient, non-alcoholic and non-smoker, with diabetes for 4 years and on regular medications, presented with pain in the upper abdomen for 4 months. The pain was dull aching, continuous, localized to the epigastric region and increased in severity over time. It was associated with vomiting immediately after food for the past 2 months. The vomiting was non-bilious, non-projectile, and contained food particles. The patient had a history of anorexia and 20-kg weight loss in the past 4 months. There was no significant family history. There was no history suggestive of metastasis.The general examination revealed a poorly built patient with pallor. Abdominal examination revealed a ballotable mass in the left lumbar region. The abdomen had no other palpable mass or clinically detectable free fluid.Upper gastrointestinal endoscopy revealed growth in the antro-pyloric region of the stomach. Biopsy of the growth showed moderately differentiated diffuse-type adenocarcinoma of the stomach. Biopsy of the mass in the left kidney revealed RCC (Figure 1).

Click to view figure 1: Histopathological sections showing (A) sheets of tumor cells (arrow) along with adjacent normal gastric mucosa (arrow head) (hematoxylin and eosin, original magnification 100) and (B) tumor cells arranged in glands (arrow) and singly scattered signet ring cells (arrow head) (hematoxylin and eosin, original magnification 200). Photomicrograph of the biopsy of the left kidney showing tumor with adjacent normal mucosa (hematoxylin and eosin, original magnification 200).